Friday, November 18, 2016

Does failure of cuff repair allow for greater range of motion in some patients?

The Relationship Between Shoulder Stiffness and Rotator Cuff Healing A Study of 1,533 Consecutive Arthroscopic Rotator Cuff Repairs

These authors reviewed 1,533 consecutive shoulders having an arthroscopic rotator cuff repair.
Patients assessed their shoulder stiffness using a Likert scale preoperatively and at 1, 6, 12, and 24 weeks (6 months) postoperatively, and examiners evaluated passive range of motion preoperatively and at 6, 12, and 24 weeks postoperatively. Repair integrity was determined by ultrasound evaluation at 6 months.

Intraoperatively, 62% of the shoulders were noted to have a full-thickness tear and 38% had a partial-thickness tear, with amean tear-size area of 3.5 ± 1.4 cm2 (range, 0 to 64 cm2; Fig. 1). Of note is that most of these patients had partial or small full thickness tears. 

An undersurface repair technique was used in 58% of the repairs, while 19%were bursal and 23% required both approaches.

After rotator cuff repair, there was an overall significant loss of patient-ranked and examiner-assessed passive shoulder motion at 6 weeks compared with preoperative measurements (p < 0.0001), a partial recovery at 12 weeks, and a full recovery at 24 weeks. 

Shoulders that were stiff before surgery were more likely to be stiff at 6, 12, and, to a lesser extent, 24 weeks after surgery (r = 0.10 to 0.31; p < 0.0001). 

A stiffer shoulder at 6 and 12 weeks (but not 24 weeks) postoperatively correlated with better rotator cuff integrity at 6 months postoperatively (r = 0.11 to 0.18; p < 0.001). 

The retear rate of patients with ≤20° of external rotation at 6 weeks postoperatively was 7%, while the retear rate of patients with >20° of external rotation at 6 weeks was 15% (p < 0.001).

Comment: From these data one might deduce that patients with a stronger fibroblastic response to surgery are more likely to have stiffer and healed repairs in contrast with those with a weak fibroblastic response who tend on average to be less stiff and heal less well. An alternate deduction is that a cuff repair is, in effect, a capsulorrhaphy (i.e. a shoulder tightening operation) and that a re-tear releases the surgically created limitation to passive range of motion.

We are not provided data on the comfort and function of these shoulders before and after surgery, so are unable to determine the relationship of stiffness and healing to the clinical condition of the shoulder before or after surgery.


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